The Physician Orders for Life-Sustaining Treatment (POLST) was developed to overcome the limitations of traditional approaches to honoring the treatment preferences of seriously ill geriatric patients by documenting treatment preferences in the form of medical orders. These standing orders are based on a conversation between a POLST facilitator (often a non-physician) and the decision-maker (patient or the legal surrogate of patients who lack decisional capacity). Once signed by the decision-maker and treating physician, POLST remains in effect until revised or revoked. Research suggests that POLST facilitates the documentation of a wide range of treatment preferences to have or decline interventions and its use directly affects treatment outcomes. POLST is used to guide the care of elderly patients in over 20 states and has been identified as a preferred palliative care practice. It is widely used in nursing facilities and hospices, where patients have significant palliative care needs. In order to ensure decision quality and avoid medical errors, POLST orders must be concordant with the decision maker's current preferences. Consistent with the goals of PA-13-354, this project is intended to advance the science of geriatric palliative care. Our objective is to evaluate the quality of POLST decisions by determining the level of discordance between POLST orders and decision- makers' preferences and describe modifiable factors associated with discordance. In order to achieve this objective, an observational, mixed-methods study will be conducted with 320 long-stay nursing facility patients or their surrogates to achieve the following specific aims: 1) Determine the level of discordance between current decision-maker (patient or surrogate) treatment preferences and standing POLST orders; 2) Identify correlates of discordance between current treatment preferences and standing POLST orders, controlling for time in days since POLST form completion; 3) Describe perceptions of the reason(s) for discordance between current treatment preferences and standing POLST orders, controlling for time in days since POLST form completion; and 4) Assess the relationship between POLST discordance and decision quality outcomes. It is expected that findings will guide improvements in advance care planning practices by identifying modifiable factors associated with POLST discordance to direct the development of tailored decision support tools and educational interventions. These data are requisite to guide improvements in clinical practice and inform policy makers working on POLST legislation and reimbursement reform at the state and federal levels.